Nursing Home Residents With Advanced Cancer May Experience Burdensome EOL Transitions

Nursing home residents with advanced cancer may experience potential end-of-life (EOL) transitions, according to study results published in Cancer.

“Nursing home residents with cancer are a growing and particularly vulnerable group of older adults,” the researchers wrote.

“Although this population is not well studied, some studies point to multiple comorbidities, a high symptom burden and high rates of hospitalization among (nursing home) residents with cancer. Advanced comorbidities and frailty increase the risks and com- plications of cancer treatment,” they added. “Therefore, we need a more comprehensive understanding of burdensome transitions of care at the EOL for this population, which could inform supportive care measures for (nursing home) residents as well as other frail older adults with cancer.”

The researchers conducted a retrospective analysis of 34,670 deceased older nursing home residents with poor-prognosis solid tumors using Medicare claims and the Minimum Data Set. They defined a potentially burdensome transition as two or more hospitalizations or an intensive care unit admission in the last 90 days of life. Also, 61.8% had a do-not-resuscitate (DNR) directive.

The average age was 82.7 years and 62.7% were female. The majority of patients had moderate to severe cognitive impairment (53.8%), full dependence in activities of daily living (66.5%) and comorbidities such as congestive heart failure (29.3%) and chronic obstructive pulmonary disease (34.1%).

The researchers found that only 56.3% of the patients used hospice at any time in the 90 days before their death. Moreover, 36% experienced a potentially burdensome EOL transition, which was higher among patients who did not receive hospice (45.4% vs 28.7%).

Potentially burdensome transitions varied by region, with the South having the highest proportion of burdensome transitions (38.2%) and the Midwest having the lowest proportion (33.7%).

Among 15,162 residents without hospice in the last 90 days of life, black race, those with comorbidities and those who received chemotherapy in the last 90 days of lifer were associated with higher odds of a potentially burdensome EOL transition. According to the multivariable analyses, full dependence in activities of daily living, congestive heart failure and chronic obstructive pulmonary disease were also associated with a higher risk of burdensome EOL transitions.

Medicaid insurance status and age were associated with lower odds of potentially burdensome EOL transitions. Compared with residents with mild or no impairment in cognition, those with moderate to severe impairment, as well as residents with a DNR directive, had lower odds of a burdensome EOL transition.

“These (nursing home) residents have significant comorbidities and functional impairment, which increase the likelihood of burdensome transitions. As the population with advanced cancer and comorbidities ages, we can expect that many will require a (nursing home) level of care,” the researchers wrote.

“It is, therefore, essential to dedicate efforts to preventing burdensome transitions in this unique population through better palliative care and facility-based initiatives. Further study of improved communication between oncologists and (nursing home) providers about EOL goals and values and policy initiatives that discourage avoidable transitions are needed to improve care for this vulnerable, growing population.”